Significance of nutritional status in the development of periprosthetic infections : A retrospective analysis of 194 patients

Malnutrition is associated with postoperative complications in elderly patients undergoing total hip arthroplasty

INTRODUCTION

Malnutrition in elderly patients with hip fracture has been described as a factor associated with poor outcomes. This evidence for elderly patients undergoing elective total hip arthroplasty (THA) for osteoarthritis is not well-established.

METHODS

We retrospectively studied a cohort of patients with an age ≥65 years admitted to the hospital for THA between January 2018 and December 2020. Demographic characteristics were collected. Albumin and total lymphocyte count were included in the pre-operative analysis and 24h postoperatively. Nutritional screening was carried out 24h postoperatively. GLIM criteria were applied for the diagnosis of malnutrition.

RESULTS

25 patients out of the total cohort of 65 (38.4%) were malnourished. Five out of six patients (83.3%) with postoperative complications presented malnutrition compared with 20 of 59 patients (33.8%) without postoperative complications (P=0.028). Mean length of stay (LOS) was 3.49±0.88 days. Five out of six (83.3%) patients with postoperative complications presented LOS >3 days compared with one out of six patients (16.6%) with LOS ≤3 days (P=0.009). 26 patients (40%) were referred to a community health centre, no differences in diagnosis of malnutrition were detected compared with patients who were discharged home. Patients with a diagnosis of malnutrition were significantly older, had a lower body mass index (BMI), a lower preoperative and postoperative albumin and worse anthropometric parameters.

CONCLUSIONS

Malnutrition is associated with postoperative complications and longer LOS in elderly patients with elective THA. Risk factors for malnutrition are older age and low BMI.

Moderate-to-Severe Malnutrition Identified by the Controlling Nutritional Status (CONUT) Score Is Significantly Associated with Treatment Failure of Periprosthetic Joint Infection

The prevalence and role of malnutrition in periprosthetic joint infection (PJI) remain unclear. This study aimed to use measurable nutritional screening tools to assess the prevalence of malnutrition in PJI patients during two-stage exchange arthroplasty and to explore the association between malnutrition and treatment failure. Our study retrospectively included 183 PJI cases who underwent 1st stage exchange arthroplasty and had available nutritional parameters, of which 167 proceeded with 2nd stage reimplantation. The recently proposed Musculoskeletal Infection Society (MSIS) Outcome Reporting Tool was used to determine clinical outcomes. The Controlling Nutritional Status (CONUT), Nutritional Risk Index (NRI), and Naples Prognostic Score (NPS) were used to identify malnutrition at 1st and 2nd stage exchange, respectively. Multivariate logistic regression analyses were performed to determine the association between malnutrition and treatment failure. Restricted cubic spline models were further used to explore the dose−response association. Additionally, risk factors for moderate-to-severe malnutrition were evaluated. Malnourished patients identified by CONUT, NPS, and NRI accounted for 48.1% (88/183), 98.9% (181/183), and 55.7% (102/183) of patients at 1st stage, and 9.0% (15/167), 41.9% (70/167), and 43.1% (72/167) at 2nd stage, indicating a significant improvement in nutritional status. We found that poorer nutritional status was a predictor of treatment failure, with CONUT performing best as a predictive tool. Moderate-to-severe malnutrition at 1st stage identified by CONUT was significantly related to treatment failure directly caused by PJI (odds ratio [OR] = 5.86), while the OR was raised to 12.15 at 2nd stage (OR = 12.15). The linear dose−response associations between them were also confirmed (P for nonlinearity at both 1st and 2nd stage > 0.05). As for total treatment failure, moderate-to-severe malnutrition as determined by CONUT was associated with a 1.96-fold and 8.99-fold elevated risk at the 1st and 2nd stages, respectively. Age ≥ 68 years (OR = 5.35) and an increased number of previous surgeries (OR = 2.04) may be risk factors for moderate-to-severe malnutrition. Overall, the prevalence of malnutrition in PJI patients is very high. Given the strong association between moderate-to-severe malnutrition identified by CONUT and PJI treatment failure, COUNT could be a promising tool to evaluate the nutritional status of PJI patients to optimize treatment outcomes.

Preoperative prognostic nutritional index is useful factor for predicting postoperative delirium after primary total joint arthroplasty

Background

Postoperative delirium (PD), as an acute brain failure, is widely reported as a very common postoperative complication, and it is closely associated with increased morbidity and mortality. Recently, malnutrition is reported as one of the risk factors for PD. The prognostic nutritional index (PNI) is a simple method for nutritional evaluation. However, few studies have discussed the effectiveness of PNI as a nutritional assessment in predicting PD after primary total joint arthroplasty (TJA). The aim of this study is to investigate potential risk factors including PNI for PD following primary TJA.

Methods

A retrospective analysis of 994 patients was performed to identify risk factors associated with PD after primary TJA by using univariate and multivariate analyses. A receiver operating characteristic curve and the area under the curve were applied to evaluate the significant results of the multivariate analysis and the optimal cutoff value (CV).

Results

Postoperatively, sixty-seven patients (67/994, 6.7 %) experienced PD. Univariate analysis demonstrated that operative time, duration of anesthesia, age, hypertension, serum albumin, and PNI differed between the PD and non-PD groups (P < 0.05). Multivariate logistic regression analysis showed that the preoperative PNI (odds ratio [OR]: 0.908; 95 % confidence interval [CI]: 0.840–0.983; CV: 47.05), age of patients (OR: 1.055; 95 % CI: 1.024–1.087; CV: 73.5 years), and hypertension (OR: 1.798; 95 % CI: 1.047–3.086), were independently associated with PD (P < 0.05).

Conclusions

A low preoperative PNI associated with malnutrition was demonstrated to be an independent risk factor for PD following primary TJA. Patients with preoperative low PNI should be cautioned and provided with adequate nutritional intervention to reduce postoperative PD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04626-6.